Sponsorship Application Form - Beautiful Minds Wellness

1
Name
First Name
Last Name
2
Phone Number
Area Code
Phone Number
3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
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Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email
example@example.com
5
Date of Birth
Date
Month
Day
Year
6
Gender
Male
Female
7
Primary Insurance
8
Secondary Insurance
9
What are your primary reasons for seeking help?
Anxiety
Depression
Mood Swings
Concentration Problems
History of traumatic event / abuse
Anger
Hallucinations
Other
10
How long have you been dealing with this problem?
Days
Weeks
Months
Years
11
Have you ever received treatment for these mental health issues?
Yes
No
12
Are you currently seeing a mental health professional for this problem?
Yes
No
13
How long have been receiving treatment?
Days
Weeks
Months
Years
14
Are you on psychiatric medication?
Yes
No
15
Have you been hospitalized for mental illness?
Yes
No
16
Do you use any substances?
Yes
No
17
How severe on a scale of 1 to 10 do you feel your symptoms are?Enter a number between 1 and 10
Number between 1 and 10
18
How do you feel these symptoms are impairing your life?
19
What areas of your life are being impaired?
None
Mild
Moderate
Severe
Work
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Family
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Row 1, Column 3
Social
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Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
School
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Work
Family
Social
School
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
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How did you hear about this program?
21
Please share why you feel you qualify for a scholarship to attend the Beautiful Minds Medical Intensive Outpatient Program or other integrative mental health treatment?
22
How motivated are you to complete the program or treatment?
Not much, but I know I should
Somewhat motivated
Very motivated
Extremely motivated
23
What will help you complete this program?
24
Are you able to commit to at least 15 consecutive days of treatment, Monday-Friday, 9am to noon?
Yes
No
25
What goals do you hope to achieve through receiving this treatment?
26
Are you willing to make changes in your daily routine that positively affect your health?
27
Are you willing to fill out a post-assessment questionnaire after you complete the program?
Yes
No
28
What is your monthly income?
Monthly Income
29
What is your combined family monthly income?
Household Monthly Income
30
How many living in the household?
31
Enter monthly income from any other sources not included above.(unemployment, SSI, pension, worker's compensation, rents, royalties, alimony, child support, other miscellaneous sources)
32
What are your total monthly household expenses?Include rent/mortgage, transportation, credit cards, insurance, entertainment, utilities, telephone, food, child care, other.
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I certify that the above information submitted is true and complete. I authorize Beautiful Minds Wellness to obtain a credit report which may be required to verify the above information. I understand this information will be held in the strictest confidence.Sign name below for e-signature.
Clear
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